Long COVID and Significant Activity Limitation Among Adults, by Age — United States, June 1–13, 2022, to June 7–19, 2023

Long COVID is a condition encompassing a wide range of health problems that emerge, persist, or return following COVID-19. CDC analyzed national repeat cross-sectional Household Pulse Survey data to estimate the prevalence of long COVID and significant related activity limitation among U.S. adults aged ≥18 years by age group. Data from surveys completed between June 1-13, 2022, and June 7-19, 2023, indicated that long COVID prevalence decreased from 7.5% (95% CI = 7.1-7.9) to 6.0% (95% CI = 5.7-6.3) among the overall U.S. adult population, irrespective of history of previous COVID-19, and from 18.9% (95% CI = 17.9-19.8) to 11.0% (95% CI = 10.4-11.6) among U.S. adults reporting previous COVID-19. Among both groups, prevalence decreased from June 1-13, 2022, through January 4-16, 2023, before stabilizing. When stratified by age, only adults aged <60 years experienced significant rates of decline (p<0.01). Among adults reporting previous COVID-19, prevalence decreased among those aged 30-79 years through fall or winter and then stabilized. During June 7-19, 2023, 26.4% (95% CI = 24.0-28.9) of adults with long COVID reported significant activity limitation, the prevalence of which did not change over time. These findings help guide the ongoing COVID-19 prevention efforts and planning for long COVID symptom management and future health care service needs.


Introduction
Long COVID includes a wide range of ongoing respiratory, neurologic, cardiovascular, and other symptoms that can last for weeks, months, or years following SARS-CoV-2 infection. Estimates of long COVID incidence among nonhospitalized adults with COVID-19 range from 7.5% to 41% (1). Long COVID places substantial strain on the health care system (2). A retrospective cohort study among eight large integrated U.S. health systems found that SARS-CoV-2 infection was associated with a 4% increase in health care utilization over the 6 months following a positive SARS-CoV-2 test result (2). Further, long COVID can have a significant impact on quality of life, functional status, and ability to work (3). A study of the 2021-2022 Omicron BA.1/BA.2 wave in Australia found that long COVID was responsible for 74% of the years lived with disability (YLD) from SARS-CoV-2 infections (4). Some populations might be at increased risk for long COVID, including those who experience more severe acute SARS-CoV-2 infection.* Adults aged ≥50 years are more likely to have severe COVID-19 than are younger persons † ; however, the risk for long COVID and significant activity limitation by age is not well characterized.

Methods
CDC analyzed data from the Census Bureau's Household Pulse Survey (HPS) from June 1-13, 2022 to June 7-19, 2023, with the exception of August 24-September 13, 2022 and November 30-December 8, 2022, when no data were collected. The HPS is a rapidly deployed, cross-sectional national survey with a 2 weeks on, 2 weeks off collection and dissemination approach designed to measure the social and economic effects of COVID-19 on U.S. households. § Long COVID questions were added to the survey beginning June 1, 2022. The HPS sampling frame was derived from the U.S. Census Bureau Master Address File and included all valid addresses with an associated mobile phone number or an email address. ¶ Respondents reported previous COVID-19 diagnosis** (i.e., ever tested positive for COVID-19 or were told by a doctor or other health care provider they had COVID-19) and current long COVID via an online survey. † † Beginning * https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/index.html † https://covid.cdc.gov/covid-data-tracker/#demographics § https://www.census.gov/data/experimental-data-products/household-pulsesurvey.html ¶ The HPS sampling frame included approximately 88% of valid addresses. Sampled housing units were contacted by both email and text message if both were available. One respondent from each sampled housing unit answered for themselves. https://www2.census.gov/programs-surveys/demo/technicaldocumentation/hhp/Phase3-9_Source_and_Accuracy_Week58.pdf ** Previous SARS-CoV-2 infection was ascertained by an affirmative response to the question, "Have you ever tested positive for COVID-19 (using a rapid point-of-care test, self-test, or laboratory test) or been told by a doctor or other health care provider that you have or had COVID-19?" † † Among respondents reporting previous COVID-19, currently experiencing long COVID was ascertained by affirmative responses to two questions: "Did you have any symptoms lasting 3 months or longer that you did not have prior to having coronavirus or COVID-19? (long term symptoms might include: tiredness or fatigue; difficulty thinking, concentrating, forgetfulness, or memory problems [sometimes referred to as "brain fog"]; difficulty breathing or shortness of breath; joint or muscle pain; fast-beating or pounding heart [also known as heart palpitations]; chest pain; dizziness on standing; menstrual changes; changes to taste/smell; or inability to exercise)" and "Do you have symptoms now?" Respondents who reported no previous COVID-19 were classified as not having long COVID.
September 14, 2022, participants were asked about significant activity limitation from long COVID (i.e., long-term symptoms significantly reduced ability to carry out day-to-day activities compared with the time before having COVID-19). § § Two-week weighted period prevalence (%) and 95% CIs were estimated for long COVID among those reporting previous COVID-19. In the interest of generating estimates for the overall adult U.S. population, prevalence (with 95% CIs) were also estimated among all adults irrespective of reported prior COVID infection. Significant activity limitation prevalence (with 95% CIs) was estimated among those with long COVID. Two-week weighted period prevalence (with 95% CIs) for long COVID and significant activity limitation were also estimated by age group. Estimates were weighted to adjust for nonresponse, survey coverage, and number of adults per household, and to match Census Bureau estimates of the population by age, sex, race and ethnicity, and educational attainment. ¶ ¶ All estimates in these analyses meet the National Center for Health Statistics Data Presentation Standards*** and are publicly available. † † † Change in 2-week period prevalence of long COVID and significant activity limitation was evaluated using Joinpoint regression. Joinpoint regression uses permutation tests to identify statistically significant points where linear trends change in direction or magnitude (i.e., joinpoints). The rate of change was tested for each trend to determine whether it was significantly different from zero, and each trend was described in the final model by percentage change (with 95% CIs) for each 2-week survey cycle. All analyses were conducted using Joinpoint (version 5.0; National Cancer Institute). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy. § § §
More than one in four adults with long COVID reported significant activity limitations during June 7-19, 2023, and § § § § https://www.ons.gov.uk/peoplepopulationandcommunity/ healthandsocialcare/conditionsanddiseases/bulletins/ ¶ ¶ ¶ ¶ In the HPS during June 7-19, 2023, 60.6% of adults aged 18-29 years reported ever having SARS-CoV-2 infection compared with 35.7% of adults aged ≥80 years. https://www.cdc.gov/nchs/covid19/pulse/longcovid.htm ***** As of May 10, 2023, bivalent vaccination coverage among adults aged ≥65 years was 43.3% compared with 20.5% among adults aged ≥18 years. https://covid.cdc.gov/covid-data-tracker/#vaccination-states-jurisdictions † † † † † Early in the pandemic, self-reported COVID mitigation behaviors including mask wearing, handwashing, physical distancing, crowd and restaurant avoidance, and cancellation of social activities were highest among adults aged >60 years. prevalence did not change over time. No significant activity limitation prevalence patterns were apparent across age groups. Limited ability to carry out day-to-day activities because of long COVID symptoms can have a significant impact on quality of life, functional status, and ability to work or provide care to others (3). Health-related quality of life scores among long COVID patients in the United Kingdom were similar to those of patients with advanced cancers, and 53% reported moderately severe functional impairment, worse than that associated with stroke (3). Long COVID in U.S. adults has also been associated with lower likelihood of working full time and higher likelihood of being unemployed (8). According to data from the New York State Insurance Fund, 18% of claimants with long COVID could not return to work for more than 1 year. § § § § § The larger economic and societal impact of long COVID could be far-reaching if working-age adults are unable to maintain employment or care for children or aging parents.

Limitations
The findings in this study are subject to at least three limitations. First, the HPS samples from housing units with at least one matched mobile phone number or email address, and thus is subject to coverage bias. Second, response rate was low for all survey cycles (range = 3.9%-7.0%). Even after weighting and adjustments for coverage and nonresponse, person-level coverage varied by some demographic characteristics. Finally, the survey did not capture duration of symptoms, COVID-19 vaccination status, time since COVID-19 illness, or treatment during acute COVID infection, each of which could influence the reported prevalence of long COVID. Despite these limitations, population-based observational studies, like the HPS, might complement studies based on administrative data by providing insight into experiences of long COVID, including among persons who might not have accessed care.

Summary
What is already known about this topic?
Long COVID includes a wide range of ongoing symptoms that can last for weeks, months, or years following SARS-CoV-2 infection.
What is added by this report?
After an initial decline, prevalence remained unchanged beginning January 4-16, 2023. Approximately one quarter of adults with long COVID report significant activity limitations.
What are the implications for public health practice?
COVID-19 prevention efforts, including staying up to date with recommended COVID-19 vaccination and planning for long COVID symptom management and health care service needs, remain important.

Implications for Public Health Practice
After an initial decline during the study period, the prevalence of long COVID has not decreased. The percentage of persons with long COVID who are experiencing significant activity limitations did not change over time. These findings highlight the importance of COVID prevention, including staying up to date with recommended COVID-19 vaccination, and could inform health care service needs planning, disability policy, and other support services for persons experiencing severe activity limitation from long COVID.